Medicaid Disproportionate Share Hospital (DSH)
On June 28, 2021 the Centers for Medicare & Medicaid Services (CMS) published a Center for Medicaid and CHIP Services (CMCS) Informational Bulletin on the monitoring and oversight of managed care in Medicaid and CHIP. The Information Bulletin outlines the requirements for the annual managed care program report required under 42 CFR § 438.66(e), institutes an appeals and grievances data collection pilot program, and provides toolkits for improved state compliance and oversight.
Managed Care Program Annual Report (MCPAR)
The May 6, 2016 Medicaid managed care final rule stipulated states must submit an annual managed care program report to CMS no later than 180 days after each contract year. The rule outlined the initial report would be due after the contract year following the release of guidance on the content and form of the report. Given the June 28, 2021 Informational Bulletin publish date, the annual reporting requirement will become effective for contract periods beginning on or after July 1, 2021. The first reports will be due December 27, 2022.
CMS provided an excel workbook which details the specific state, program, or health plan level information required. The report will be collected electronically through a web-based submission portal that will be available no later than June 27, 2022. The portal will collect the exact information contained in the excel workbook. The standard data collection tool will allow CMS to compare state managed care programs based on nationwide data, and identify areas which states may need assistance in improving their programs as well as monitor compliance with managed care regulations.
The report will collect information in the following categories for Managed Care Organizations (MCOs), Prepaid Inpatient Health Plans (PIHPs), and Prepaid Ambulatory Health Plans (PAHPs). For Primary Care Case Management (PCCM) entities, the report will be limited to program enrollment and service area expansions and grievances, appeal, and state fair hearings information.
- Program enrollment and service area expansions
- Financial performance
- Encounter data reporting
- Grievances, appeals, and state fair hearings
- Availability, accessibility, and network adequacy
- Delegated entities
- Quality and performance measures
- Sanctions and corrective action plans
- Beneficiary support system (BSS)
- Program integrity
CMS strongly encourages states to review the excel workbook version of the report to begin planning necessary changes in states’ data collection process to complete the report.
Appeals and Grievance Data Collection Pilot
Over the next 12 to 18 months, CMS will pilot a standard appeals and grievances data collection tool to be used for the first year of implementation for states that are completing their readiness review process within that timeframe. Based on results of the pilot, the tool will be edited as necessary, and be incorporated as a component of the standard readiness review process. CMS believes appeals and grievances data can provide critical insight into a managed care program’s performance, especially in the first year of implementation.
Technical Assistance Toolkits
CMS developed a Behavioral Health Access Toolkit and Quality Strategy Toolkit to support states in ensuring behavioral health network adequacy contract requirements are met and in implementing quality strategy requirements. The toolkits are available on Medicaid.gov at https://www.medicaid.gov/medicaid/managed-care/guidance/medicaid-and-chip-managed-care-monitoring-and-oversight-initiative/index.html.
CMS is the in process of developing additional technical assistance toolkits on the following topics:
- Managed Long-Term Services and Supports
- Managing Plan Transitions
- Provider Screening and Enrollment
- Program Integrity
- Tribal Protections in Medicaid and CHIP Managed Care
CMS is also developing standard templates for the Medical Loss Ratio Summary Report required in 42 CFR § 438.74(a) and the Access Standards Report required in 42 CFR § 438.207(d) and (e).
State Action Items for MCPAR Compliance
As states consider the new CMS guidance related to monitoring, oversight, and reporting, they should consider how this guidance needs to be incorporated into future requests for proposals for managed care contractors. States should also review their managed care contract templates to determine if contract language for future contracts should be modified to reflect the guidance for support in the readiness review and ongoing contract monitoring processes.
Data Collection and Validation Process
States should immediately begin assessing the information required in the MCPAR and ensure they are currently collecting, as well as validating, the data necessary to accurately complete the required data components.
State Monitoring Program
Based on review of the data components required in the MCPAR, states need to perform an assessment of their current monitoring program confirming all ten MCPAR topic areas are addressed. Additionally, they should be able to demonstrate action plans are in place to address areas in which health plans are not meeting states expectations or requirements.